Provider Demographics
NPI:1659911550
Name:OPTIMAL PERFORMANCE MEDICINE, LLC
Entity Type:Organization
Organization Name:OPTIMAL PERFORMANCE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JORDAN
Authorized Official - Last Name:WASHBURN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:970-518-9394
Mailing Address - Street 1:611 E CARLSON ST STE 117C
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4311
Mailing Address - Country:US
Mailing Address - Phone:307-514-0510
Mailing Address - Fax:
Practice Address - Street 1:611 E CARLSON ST STE 117C
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4311
Practice Address - Country:US
Practice Address - Phone:307-514-0510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty